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Peri-op Fluid Management
M. Greschner MDCM,FRCPC Assistant Professor (Anesthesia) Dalhousie University
Assistant Professor (Anesthesia) Universite de Sherbrooke
Disclaimer
...I wish!
ERASEnhanced Recovery After Surgery
Early Release After Surgery
Objectives• Describe and calculate perioperative
physiological fluid requirements for patients of all ages
• Describe and calculate intraoperative fluid requirements for open abdominal surgery
• Describe and calculate fluid replacement for replacing blood loss
NOTICE!
The case presentation is
fictitious.
NOTICE!
MATH
Variability in practice and factors predictive of total crystalloid
administration during abdominal surgery: retrospective two-centre analysis
M. Lilot1,2, J. M. Ehrenfeld3, C. Lee1, B. Harrington1, M. Cannesson1 and J. Rinehart
British Journal of Anaesthesia 114 (5): 767–76 (2015)
UCI: 1327 VU: 4585
Peri-op Fluid Management
Preoperative Phase
Intraoperative Phase
Postoperative Phase
4-2-1 Rule
4-2-1 RuleBody Weight Hourly Fluid Requirement
0 - 10 kg 4ml/kg/h
11 - 20 kg 40ml/h + 2ml/kg/h
21 kg and up 60ml/h + 1ml/kg/h
Perianesthesia Cup
4-2-1 Rule5 Kg Child 20 ml/h
10 Kg Child 40 ml/h
15 Kg Child 50 ml/h
20 Kg Child 60 ml/h
30 Kg Child 70 ml/h
70 Kg Adult 110 ml/h
Mrs. Jane Doe
58y.o. female Diverticulitis Sigmoid resection (2hrs) at 14:00 NPO since 00:00 Weight: 60 kg
Preop PhaseWhat is Jane's fluid deficit at 12:00hrs?
4-2-1 rule per hour X hrs NPO
100ml/h X 12 = 1200ml
What is Jane's fluid deficit at 14:00hrs?
100ml/h X 14h = 1400ml
Intraop Phase
• Basic Requirements (4-2-1) continue
• Evaporative losses due to open abdomen
• 10ml/kg/h
Intraop PhaseAbdomen is open for 2 hours: What is the evaporative loss?
10ml/kg/h X 2h
10 X 60 X 2 = 1200ml
Intraop PhaseWhat is the total fluid requirement at the end of the case?
Preop maintenance 1400ml+ +
Intraop maintenance 200ml
Evaporative losses+ +
1200ml
Total Requirement 2800ml
But Wait!
There's More
Replacing Intraoperative Blood Loss
A) Allowable Blood Loss
4 mls of RL are needed to replace 1 ml of blood
B) 4:1 Rule
Transfusion TriggerInitial HgBEstimated Blood Volume
Allowable Blood Loss
Starting HgB
Transfusion Trigger
EBV
130
70
4200ml
1938ml
Replacing Intraoperative Blood Loss
1000ml Blood 4000ml RL
Intraop PhaseWhat is the total fluid requirement at the end of the case?
Preop maintenance 1400ml+ +
Intraop maintenance 200ml
Evaporative losses+ +
1200ml
Total Requirement 2800ml
Good Job, Doc!
Postop Phase
• Continue Fluid Resuscitation
• CBC?
• PT/PTT?
• Electrolytes?
